Deltopectoral approach

The deltopectoral approach is the mainstay of open anterior shoulder surgery. This is an ideal interval when performing the open Bankart procedure. Our specific technique for the open Bankart procedure using this approach is described later in this chapter.

The skin incision for the deltopectoral approach has classically been described as extending from just proximal to the coracoid distally toward the axilla. ^, The internervous plane between the deltoid and the pectoralis major is developed, and the dissection is carried down to the level of the subscapularis. The cephalic vein overlies the deltopectoral fascia, serves as a landmark in this interval, and can be retracted medially or laterally. Our preferred technique is to retract the cephalic vein laterally, preserving contributing vessels. To visualize the clavipectoral fascia overlying the subscapularis deeper in the interval, self-retaining linked retractors are used, retracting the deltoid laterally and pectoralis medially. ^, The fascia is divided just lateral to the conjoint tendon at the coracobrachialis to allow for access to the subscapularis. The dissection is carried superiorly to the coracoacromial ligament, at which point retractors can be placed deeper in the interval.

Once the subscapularis is encountered, the superior and inferior borders should be identified. There are a number of methods for taking down the subscapularis tendon, including sharply dissecting the entire tendon, a portion of the tendon, or a T-shaped split. Our preferred technique is an L-shaped incision with the longitudinal limb extending down from the level of the rotator interval to just above the anterior circumflex vessels, and the transverse limb carried medially, leaving a small stump of tissue on the lesser tuberosity for later repair. Importantly, the subscapularis is raised in a discrete layer from the underlying capsule.

At this point, the anterior capsule is in view. A T-shaped capsulotomy has been classically described to allow for visualization of the glenohumeral joint. ^, Our preferred technique is to create a longitudinal incision in the capsule laterally, at the level of the humerus, then a horizontal limb directed medially at the midlevel of glenoid with the extremity in approximately 30 degrees of external rotation. Tagging sutures can be placed on the superior and inferior leaflets to improve exposure and allow for later approximation. At this point, retraction can be deepened and articular work performed.

Leslie-Ryan approach

Alternative approaches to the anterior shoulder have been described, including by Leslie et al. This approach offers potential cosmetic advantage over the anterior incision described earlier. The patient is positioned supine with the extremity abducted. The incision for this approach lies distally to the previous discussion. The incision begins at the level of the anterior axillary fold and extends posteriorly into the axilla. The incision within the axilla is out of view and generally can heal without tension. The subcutaneous flaps are developed bluntly to expose the deltopectoral interval and the cephalic vein as described previously. This incision can be extended proximally to join the previously described anterior deltopectoral approach if additional exposure more superiorly is required.

Open bankart indications

The precise indications for deciding between an open and arthroscopic technique continue to be widely contested, and many younger surgeons do not have significant experience with the open Bankart procedure. We consider a “moderate” amount of glenoid bone loss (10% to 20% of glenoid bone width) to be a preferred indication for open Bankart repair in lieu of arthroscopic-only technique, potentially used in the setting of less bone loss, or bone augmentation operations in the setting of greater bone loss. The notions of “critical bone loss” and “engaging” Hill-Sachs lesions were classically described by Burkhart et al. as indications for an open procedure (which may include bone augmentation procedures). Several authors, including Arciero et al., have also touched upon the challenges of glenoid bone loss when attempting soft tissue reconstruction of the anterior labrum. This notion has more recently been further refined by Shin et al., who have identified 17.3% anterior to posterior width of the glenoid to be the point above which recurrence of instability is likely following an arthroscopic repair. Shaha et al. and Dickens et al. have suggested that a cut-off of 13.5% of glenoid diameter is most appropriate for determining the point at which an approach other than arthroscopic should be used. Clearly, there is a cut-off of glenoid bone loss above which arthroscopic Bankart repair alone is not an optimal solution. Our preferred method of measuring bone loss is to incorporate three-dimensional imaging to assess thoroughly the amount of glenoid bone loss. Glenoid bone loss greater than 10%, as discussed later in this section, is a cause for careful consideration for abandoning the arthroscopic Bankart repair in these patients.

A revision setting may also prove to indicate a role for the open technique. Although revision surgery is never ideal, the open Bankart technique has proven to be a reliable option to prevent instability in patients who have not responded to an index procedure, including arthroscopic Bankart procedures. Collision athletes present a challenging population for glenohumeral instability. In a 2017 review, Leroux et al. noted that the recurrence rate of anterior instability, following arthroscopic-only stabilization techniques, was as high as 17.8% in patients who participated in collision athletics but did note that, with proper surgical technique (exclusion of patients with significant bone loss, use of at least three anchors, and utilization of the lateral decubitus position), rates were lower, at 7.9%.

In general, we consider patients with 10% to 20% glenoid bone loss (intermediate, or “subcritical” bone loss), particularly those who are collision athletes or younger than 20 years, as well as those with poor capsulolabral tissue in the setting of multiple dislocations (more than 5 dislocation events), to be indicated for the open Bankart procedure. These indications are similar to those previously described by Gill et al.

Open bankart repair—introduction

In recent years, partly due to improvements in arthroscopic technology, implant design, and surgical training/surgeon comfort, the arthroscopic Bankart repair has become a significantly more commonly used method to treat patients with anterior shoulder instability. The chief complication of concern when assessing the difference in success between arthroscopic or open surgical outcomes in management of glenohumeral instability is the presence of recurrent instability events (dislocation or subluxation events). Recurrent instability events, in addition to likely loss of time from sport, or work, also carry the risk of subsequent pathology, including advanced chondral damage, and bone pathology necessitating larger and more complex surgical interventions. Thus preventing recurrence of dislocation is of paramount importance. Several recent studies have suggested similar or even lower recurrence rates of dislocation in patients undergoing open rather than arthroscopic Bankart repair.

Although lower recurrence rates are important for determining the success of surgical intervention for instability, subjective outcomes scores are also important to discuss. Studies have demonstrated that, even in the absence of instability, an arthroscopic-only approach in the setting of significant glenoid bone loss resulted in lower subjective outcome scores, such as the Western Ontario Shoulder Instability Index outcome score.

A recent large review identified similar “nondislocation” complication profiles in patients undergoing open soft tissue stabilization procedures compared with those undergoing arthroscopic stabilization procedures. They noted only a slight increase in potential for infection or persistent pain compared with the arthroscopic alternative. A further discussion of outcomes and complications for open versus arthroscopic repairs is included later in this chapter.

The open surgical reconstruction of the avulsed capsule and labrum of the anterior glenoid is a historically trusted procedure in the setting of anterior glenohumeral instability. Despite the increasing popularity of the arthroscopic technique in recent years, the open Bankart procedure remains a dependable, reproducible procedure, showing good results in patients 10 or more years after initial surgery with good rate of return to contact sports and low recurrence rates. ^, Bankart described the procedure in 1923 as a method of stabilizing the shoulder, returning athletes to play and decreasing the risk of further instability events. Although changes have been made to Bankart’s original procedure, the notion of direct capsulolabral repair of the anterior glenoid has remained a mainstay of anterior instability surgical treatment.Videos 32.1 to32.10 demonstrate the technique of open stabilization as described by Matsen.

Patient demographics and procedure choice

Patient selection is paramount to establishing predictable outcomes. As with any condition, there is no one best solution for all patients. Patient age, sex, presence of ligamentous laxity, history of previous instability events, athletic demands, occupational demands, presence of osseous pathology, physical exam findings, and medical history are all factors that must be considered when establishing the optimal treatment for these patients. A multitude of procedures have been described to address anterior shoulder instability, including both open and arthroscopic procedures, and both bone augmentation and soft tissue–only procedures. Bone augmentation procedures, including the Latarjet procedure, are discussed in a separate chapter, and a more detailed discussion of arthroscopic management has been provided in Chapter 31 . However, we will briefly discuss the role of arthroscopic management in the context of its role alongside open management. We believe that a competent grasp of both arthroscopic and open management of anterior instability is essential to completely manage all patients, who can present with extremely diverse pathoanatomy.

Chapter 31 describes the procedural steps and considerations for addressing anterior instability arthroscopically. When identifying the best management for an individual, the benefits and drawbacks of both open and arthroscopic procedures must be weighed. Previous studies have noted that arthroscopic technique may provide for earlier range of motion with predictable outcomes, specifically among those patients who do not have glenoid bone loss. Ozturk et al. demonstrated a predictable return to sports among patients younger than the age of 25 years. However, they also noted an increased rate of recurrent instability among those patients who had Hill-Sachs lesions, multiple episodes of preoperative instability (>5), and ligamentous laxity, indicating a potential need for alternative in this group. Patients at risk for recurrence with arthroscopic management are more appropriately indicated for open stabilization. Balg et al. described the Shoulder Instability Severity Index Score, which helps to identify various risk factors for recurrent instability; these are patients at risk for failure of an index arthroscopic procedure. These risk factors included age younger than 20 years at time of surgery, involvement in contact sports, shoulder hyperlaxity, Hill-Sachs lesion present on an anteroposterior radiograph in external rotation, and loss of the inferior glenoid contour on plain radiographs ( Figs. 32.1 to 32.3 ). These authors identified these patients as individuals who would have an unacceptably high risk of failure with arthroscopic management. These patients represent a group for which management with an open Bankart procedure should be considered.

Axillary view of glenoid with blunting of anterior aspect and loss of contour.

Absence of normal contour and subcortical line at glenoid.

Noted normal contour of the inferior glenoid with complete subchondral cortical line.

Although physical exam and radiographic findings may be similar among various patients, demographic information is key in determining the risk factors for dislocation in these patients. Several studies have illustrated that participation in collision sports puts patients at several times increased risk for recurrent dislocation postoperatively. Cho et al. found a nearly threefold increased rate (17% overall) of recurrent dislocation following arthroscopic Bankart repair in patients who participate in collision sports. In addition, Nakagawa et al. recognized that younger age at index procedure and presence of glenoid bone defect are also well-described risk factors for recurrence of instability following arthroscopic repair.

Although multiple studies, such as those detailed earlier, have helped to identify patients at risk for recurrence, studies to validate these risk factors have had mixed results in terms of the ability to predict arthroscopic failure. As with most surgical interventions, obtaining an optimal outcome at the time of index procedures is important to prevent a revision surgery situation. Anterior glenohumeral stabilization is no exception to this rule—a thorough assessment to best produce a good surgical result, without recurrent instability, during the index procedure is necessary. Furthermore, a careful assessment of patients undergoing revision surgery must be done because revision surgery is often less predictable than index procedures. Although there is a role for revision arthroscopic procedures, there is also certainly a role for the open Bankart in patients with failed index procedures.

With the aforementioned information in mind, a personalized algorithm for management of this condition is warranted. A young collision sport athlete with intermediate (10% to 20%) glenoid bone deficit may benefit from an open approach compared with an arthroscopic repair. Recent literature has increased attention to glenoid bone deficiency when selecting operative intervention in these patients. Although the arthroscopic technique was previously used for glenoid defects of 20% or more, recent data from Shaha et al. have demonstrated that a glenoid deficiency of greater than 13.5% is considered “critical.” Bone loss greater than 13.5% was associated not only with increased risk of dislocation postoperatively but also lower subjective outcomes, even in the absence of recurrent instability. Dickens et al. similarly have supported the notion of the upper limit of tolerated bone loss for an arthroscopic approach being 13.5% of the glenoid.

Patients should be counseled regarding the aforementioned data and risk factors, and a surgeon treating this condition should have multiple surgical options as part of his or her armamentarium—specifically, both open and arthroscopic approaches.

Authors’ open bankart technique

Our preferred technique for the open Bankart procedure is described as follows.

Patients are positioned in a modified beach chair position with the torso elevated 20 to 30 degrees from a straight supine position following induction with general anesthesia. Chemical paralysis is used to ensure complete muscle relaxation. Maximal surgical exposure is obtained with attention to head and chest wall positioning, ensuring operative field extension to the sternoclavicular joint. The patient is elevated approximately 30 degrees from the flat supine position, and a rolled bump is used under the operative-side scapula to provide protraction and eventual improved exposure of the surgical site. A padded Mayo stand is positioned under the operative arm and is used to allow for intraoperative manipulation of arm positioning. An exam under anesthesia is done to assess the degree of pathologic laxity, including performing a load-shift maneuver. If the shoulder dislocates and “locks out” requiring manipulation to reduce, this typically indicates substantial bone loss.

An initial arthroscopy is performed to verify presence (or absence thereof) of intra-articular pathology and to reconcile this with the findings that were identified on preoperative imaging (magnetic resonance imaging and/or computed tomography).

An anterior axillary incision is made from the level of the coracoid that heads inferiorly toward the axilla ( Fig. 32.4 ). Dissection is performed down to the level of the deltopectoral fascia, the deltopectoral interval is developed, and the cephalic vein is identified and retracted laterally. It is important to open the deltopectoral interval from just distal to the clavicle to the falciform ligament of the pectoralis major tendon; this enhances deeper exposure ( Figs. 32.5 and 32.6 ). Once the cephalic vein has been dissected out, generally laterally, a self-retaining retractor is placed to provide visualization. The deltopectoral interval and the clavipectoral fascia are then identified and split lateral to the conjoint tendon, and the coracoclavicular ligament is released. At this point, retraction is deepened to the interval between the deltoid and the deeper conjoint tendon medially, with placement of a link retractor ( Fig. 32.7 ).

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